Economics of the Heart


Washington. -- For a quick course in why health-care spending continually eludes stringent efforts at cost control, consider a family of wondrous mechanical devices headed for the medical marketplace to take over from failing hearts -- which now number 700,000 a year in the United States.

There's a long way to go in perfecting these devices, but they are already considerably more sophisticated and effective than the cumbersome Jarvik-7 artificial hearts that created a sensation in the 1980s. And they are bound to be very costly, with estimates running at $150,000 to $200,000 per implant. But at this stage, that's a guess, as is the number of eligible patients, estimated at between 35,000 and 80,000 a year. Costs can be controlled by edict of insurance systems, but there should be no surprise if the patient load exceeds estimates in an aging nation hooked on high-tech medicine.

In any case, when mechanical heart devices begin to arrive on the market in sizable numbers, probably within a decade, they are destined to add billions of dollars to the national medical bill, currently a world-leading 12 percent of gross national product.

Basically two types of mechanisms for the ailing heart are in the works. Both are fully implantable and use compact power sources, unlike the Jarvik-7, which depended on a large and noisy external compressor.

One, known as a ventricular-assist device, pumps blood to and from the heart to assist one or both ventricles. In limited trials, it has been used as a temporary device to assist ailing hearts, usually to tide a patient over until a complete heart transplant can be performed.

The other device, the total artificial heart, is for full replacement of failing hearts, a procedure which is now severely limited by a shortage of transplantable human hearts. The supply of human hearts, about 2,000 per year, is sufficient for only 10 to 20 percent of patients who are considered suitable for a heart replacement.

As detailed in a recent review of mechanical heart research by the Institute of Medicine, which advises the federal government on health-policy issues, research on both devices is advancing rapidly toward important decision points. In 1988, the National Heart Institute, source of almost all funds for mechanical heart research, decided to phase out research on total heart replacement and concentrate on the ventricular device. Congress, always keen for medical research, balked at that priority choice and the Heart Institute extended the research to 1993.

In its recent report on mechanical-heart research, the Institute of Medicine recommended a continuation of the research on both types of device because of the limited therapeutic role of the ventricular device. The recommended research costs are modest, $5 million to $10 million a year. But the long-term implications for the medical economy could be colossal. The institute therefore accompanied its advice with cautions about the need for sober evaluations of the cost-effectiveness of total heart replacement.

The warnings are necessary, because there should be no doubt that along with medical therapy, the heart researchers are working on economic dynamite. The design of an effective total mechanical heart is difficult but doable. The Institute of Medicine forecasts that a workable model will not receive government approval before the year 2005. But, with enough money, technology often progresses in rapid, unpredictable spurts.

Given the extent of fatal heart disease, mechanical heart transplants portend an unprecedented surge in medical expenditures. The direct costs will be monumental, but they will also be enlarged by the costs of surviving patients eventually becoming prey to other diseases of aging.

Frugality in providing all necessary medical services is one solution. Rationing -- the denial of useful treatments -- is another. But, despite endless debates about the financing of health care, America has shown little interest in either.

The burden of the inexorable rise in our health-care spending was recently cast in dramatic terms by Charles A. Bowsher, head of the General Accounting Office, Congress' financial watchdog. "If U.S. spending on health care, relative to our national income, had increased only as fast as Canada's, the United States could be devoting today over $140 billion to other uses. This sum is equivalent," he said, "to over 40 percent of all national outlays on education."

And that's at a level of 2,000 heart transplants per year.

Daniel S. Greenberg publishes the newsletter Science & Government Report.

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